John Launer: The art of paying attention

I’m not sure that I’ve ever been an exceptionally compassionate or empathetic doctor, and it would be for patients to say, rather than me. Possibly they’d have a range of views, depending on whether we got on well or my treatment made them better. Altogether, I’m a bit suspicious of training and publications that describe how to develop empathy and compassion (sometimes subtly implying saintliness in their authors), so in my own teaching I generally try to avoid tackling these topics head on.

There are other qualities I prefer to focus on. Rita Charon, a New York physician and a pioneer in the field of narrative medicine, emphasises three qualities that she believes we should promote in medicine: attention, representation, and affiliation.1 She describes attention as “the most pivotal skill with which to endow a health professional who wants to be a healer.” By representation she means the capacity to give a faithful and accurate account of a patient’s words, images, thoughts, and utterances. Affiliation follows from these, when we bring our full selves into our practice.

When I’m teaching I like to focus on attention, although I usually prefer the term “attentiveness,” as it implies something more continuous. It highlights the idea that defines narrative medicine: you can apply close reading to a patient’s story in the same way you can to a literary text. Attentiveness carries nuances of both empathy and compassion, without the risk of judgmental overtones. Most important of all, it can be translated into a set of skills for careful questioning, listening, and responding that you can readily teach and learn.

Among the skills for attentiveness that I find most useful to teach are “noticing the words we usually ignore” and “taking the temperature of the conversation.” Regarding the first of these, I’m always interested in statements such as, “My headaches are driving me to despair.” Ninety-nine times in 100 we ask about the headaches and never inquire about the “driving to despair.” Why did that person, consciously or unconsciously, select that exact phrase—and what more will we learn about their life, and possibly even the cause of the headaches, if we’re curious about this and ask them to unpack it?

The other skill involves what are sometimes called “meta-questions.” These are questions such as: “What are you hoping to get from this consultation?” “How are we doing so far?” “Have I missed out anything you asked?” “Is it OK to wind up now?” Almost every time I teach these and other similar skills, someone is almost bound to object that it will be unnecessarily time consuming. Yet almost everyone who applies them reports that it helps them get to the heart of things in consultations far more quickly.

The US physician and ethicist Jay Katz once criticised the “dogma” in medicine of “assuming an identity of interests and brushing aside the need to clarify differences in expectations and objectives through conversation.”2 It’s one of my favourite quotations. The antidote to this dogma is attentiveness. And whenever we apply it, I suspect that many patients experience it as empathy and compassion, even if we don’t think of it as such.